<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610111
Report Date: 09/10/2024
Date Signed: 11/01/2024 02:23:57 PM

Document Has Been Signed on 11/01/2024 02:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CALIFORNIA STATE HEALTH GROUP LLCFACILITY NUMBER:
197610111
ADMINISTRATOR/
DIRECTOR:		ANDRANIK KAPIKYANFACILITY TYPE:
740
ADDRESS:9526 SALOMA AVETELEPHONE:
(818) 810-9339
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 6DATE:
09/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Isaiah Phiri- DesigneeTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This case management visit is conducted by Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Gina Saucedo, in conjunction with a complaint investigation visit to this facility.

On 9.10.2024, LPAs conducted an unannounced complaint visit to this facility in conjunction with complaint control #31-AS-202409041331017. LPAs met with the staff Isaiah Phiri, and the reason for the visit was disclosed.

LPAs could not conduct a records review of residents and staff. Staff designee could not release records to LPAs for review. Therefore, interview with administrator over the phone, it was concluded that the facility did not provide records required for LPA. The designee MUST be able to act in administrator stead including but not limited to accessing files and records at any time.

Under Title 22 Regulations, the following citation is issued and recorded on LIC809-D.

No immediate health and safety hazard is noted at the time of this visit. Exit interview was conducted. Appeal rights discussed and a copy of report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/01/2024 02:23 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 09/10/2024 at 01:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CALIFORNIA STATE HEALTH GROUP LLC
FACILITY NUMBER: 197610111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2024
Section Cited
CCR
874059(a)

1
2
3
4
5
6
7
When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have the qualifications adequate to be responsible and accountable for management and administration of the facility.
1
2
3
4
5
6
7
Administrator or designee should provide proper records for LPA to review when a visit is conducted. The designee MUST be able to act in administrator stead including but not limited to accessing files and records at any time.
8
9
10
11
12
13
14
Based on LPA’s observations and interaction with the administrator, the administrator refused to respond to the facility to provide records to the LPA and had no Designee to act in his stead. This resulted in a potential risk to the health and safety of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2